Poverty and antibiotic misuse: a complex association
Authors: Celestino Obua, Zohray Talib, Jessica E Haberer
Journal: The Lancet Global Health (2022)

The accidental discovery of penicillin from Penicillium mould in the early 20th century1Fleming A On the antibacterial action of cultures of a penicillium, with special reference to their use in the isolation of B influenzæ.Br J Exp Pathol. 1929; 10: 226-236Google Scholar heralded the earliest use of antibiotics for the treatment of bacterial infections in humans. This discovery was followed by the era of extensive research and development of new antibiotics.2Lobanovska M Pilla G Penicillin's discovery and antibiotic resistance: lessons for the future?.Yale J Biol Med. 2017; 90: 135-145PubMed Google Scholar Thereafter, the widespread use of antibiotics was thought to be the dominant factor in the emergence and spread of antibiotic-resistant bacterial pathogens.3Finland M Emergence of antibiotic resistance in hospitals, 1935–1975.Rev Infect Dis. 1979; 1: 4-21Crossref PubMed Scopus (100) Google Scholar In The Lancet Global Health, Dominique L Green and colleagues4Green DL Keenan K Fredricks KJ et al.The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda.Lancet Glob Health. 2023; 11: e59-e68Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar investigated the role of poverty and related factors in the misuse of antibiotics as drivers for antimicrobial resistance. A key finding of the Article suggests that, among the study populations, people not experiencing poverty in their standard of living were more likely to misuse antibiotics than those who were the most deprived. This study contradicts previous studies that suggested a more dominant role of poverty in antibiotic misuse and as a driver to antimicrobial resistance.5WHOOvercoming antimicrobial resistance. World Health Organization, Geneva2000Google Scholar The authors' investigation of poverty using the multidimensional poverty index (MPI) aligns itself to the paradigm that was espoused by Rolain and colleagues,6Rolain JM Canton R Cornaglia G Emergence of antibiotic resistance: need for a new paradigm.Clin Microbiol Infect. 2012; 18: 615-616Summary Full Text Full Text PDF PubMed Scopus (43) Google Scholar that the emergence of antibiotic resistance is a complex interaction between the infectious microbial agents, the antibiotic, and the antibiotic resistance genes. Although the study by Green and colleagues7Sharma VK Johnson N Cizmas L McDonald TJ Kim H A review of the influence of treatment strategies on antibiotic resistant bacteria and antibiotic resistance genes.Chemosphere. 2016; 150: 702-714Crossref PubMed Scopus (496) Google Scholar did not investigate the microbial agents and genes for antibiotic resistance, their investigation into the use of antibiotics addresses itself to the complexity of the misuse of antibiotics, whereby the use of antibitotics can activate resistance genes within the bacterial agents, even though some resistance genes might develop de novo. Humans, through their misuse of antibiotics, are responsible for the emergence of antimicrobial resistance. In Green and colleagues' Article, poverty across three east African countries (ie, Kenya, Tanzania, and Uganda) was investigated using an adapted version of the internationally recognised acute MPI, which accounts for multiple dimensions of wellbeing—namely, education, health, and living standards—and their associations with misuse of antibiotics. Data were collected on 6827 outpatients, of whom 6345 patients had complete data (5034 [79·2%] female individuals, 3840 [60·5%] younger than 35 years, 2621 [41·3%] worked in informal employment, and 2488 [39·2%] had primary-level education). The MPI used suggested that antimicrobial resistance was driven by two key factors in which humans have roles: (1) the set up and functioning within health systems to promote affordable and easy access to antibiotics, and (2) ensuring the appropriate use of the antibiotic at the individual level and community level.8Dyar OJ Obua C Chandy S Xiao Y Stålsby Lundborg C Pulcini C Using antibiotics responsibly: are we there yet?.Future Microbiol. 2016; 11: 1057-1071Crossref PubMed Scopus (27) Google Scholar Affordability and accessibility are both responsive to economic factors (eg, access to qualified health providers, transport to health facilities, and ability to purchase the prescribed antibiotics), and appear to affect people from across the MPI spectrum in the current study. Poverty, presented as degrees of deprivation using the MPI, was not substantially different among the participants in the three countries, although the indices were worst among participants in Uganda. Although the authors' approach is informative, they might have missed the opportunity to explore the use of explanatory models (eg, the Model of Health Behavior in Vulnerable Populations9Gelberg L Andersen RM Leake BD The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.Health Serv Res. 2000; 34: 1273-1302PubMed Google Scholar) to provide meaning to the nuances observed across the MPI spectrum. The finding that people who are the most impoverished are the least likely to misuse antibiotics was covered to some extent with the focus-group discussions; however, there is still an opportunity to explore the contextual and cultural factors in future studies, to deepen understanding of the relationship between poverty index and antibiotic misuse as drivers for antimicrobial resistance. Although the Article presents financial constraints and care commitments, work commitments, inconveniences, and under-resourcing of health facilities reported by participants as challenges to best practice in implementing antibiotic use, these factors were found to be common among the participants irrespective of the degree of deprivation (poverty). Therefore, further research to determine the veracity of the study's findings needs to be performed that considers potential bias in reporting (eg, social desirability and misclassifications). Overall, the findings from this study challenge practitioners and researchers to further investigate the complex human–antibiotic–bacterial interaction, to provide a clearer understanding of the association between poverty and antimicrobial resistance. This study mostly presented factors correlating to antimicrobial resistance among women who attended outpatient clinics in three east African countries. Acknowledging the limitations and strengths of the study, the key take-home messages are the importance of looking beyond education as an intervention to address antimicrobial resistance, given that knowledge does not necessarily lead to better antibiotic use; and the absence of a correlation between poverty and antimicrobial resistance. The Article by Green and colleagues adds to the body of knowledge and provides important contributions to and insights about current practice and research in antibiotic misuse as drivers of antimicrobial resistance within the east African region, and possibly in other sub-Saharan African countries. JEH reports consulting fees from Merck and stocks in Natera. CO and ZT declare no competing interests. The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and UgandaWe should not assume that higher deprivation drives antibiotic misuse. Structural barriers such as inefficiencies in public health care, combined with time and financial constraints, fuel alternative antibiotic access points and treatment non-adherence across all levels of deprivation. In designing interventions to reduce antibiotic misuse and address antimicrobial resistance, greater attention is required to these structural barriers that discourage optimal antibiotic use at all levels of the socioeconomic hierarchy in LMICs. Full-Text PDF Open Access